F0755

D

Failure to Provide Ordered Pain Medication and Follow Medication Administration Policy

Glenwood, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own Medication Administration policy, resulting in a resident not receiving a prescribed pain medication for multiple days. The resident reported not receiving her ordered Pregabalin 50 mg oral capsule, taken every morning for pain, for more than five days and stated she had asked staff why the medication was not in the medication cart. Review of the Medication Administration Record (MAR) for the month showed that Pregabalin was not given on six specific dates, and the Controlled Drug Record indicated the last dose was administered several days before those missed doses. The resident also stated she avoids using her PRN Hydrocodone-Acetaminophen 5-325 mg due to constipation issues.

Interviews with facility leadership confirmed expectations that when a medication is not available in the nurse’s cart, nurses should obtain it from the electronic medication dispenser or contingency supply and contact the pharmacy if needed, as well as document reasons for missed doses on the MAR and notify the provider when required. The Administrator stated that nurses are able to locate medications in the facility’s electronic medication dispenser when they are not in the cart. The DON explained that a “9” on the MAR indicates the medication was not given and that nurses are expected to retrieve medications from the emergency supply and notify the physician if a refill is needed. The facility’s written Medication Administration policy requires that if a medication is ordered but not present, staff must check for misplacement, call the pharmacy, and obtain it from contingency or convenience stock if available, and document reasons for any missed doses on the MAR, which did not occur in this case.